Provider Demographics
NPI:1649216953
Name:BUSTAMANTE, CARLOS I (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:I
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20814 W DIXIE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180
Mailing Address - Country:US
Mailing Address - Phone:305-933-8433
Mailing Address - Fax:305-933-9115
Practice Address - Street 1:20814 W DIXIE HIGHWAY
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180
Practice Address - Country:US
Practice Address - Phone:305-933-8433
Practice Address - Fax:305-933-9115
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059145207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054309800Medicaid
11784Medicare ID - Type Unspecified
B68723Medicare UPIN